Friday, June 21, 2013

Gardasil is good

Crowdsourcing of medical decisions seems to be more and more common. Spend even a little time on Twitter or Facebook and you will see people posing medical questions to "the crowd." Since crowdsourcing is inevitable, it does no good to whine about the questionable practice of asking groups of (not so) random people for medical opinions. Medical professionals have an obligation to educate, and these questions can generate useful and lively discussions; they are opportunities.

The other day a friend (a real friend) posed a question on Facebook: Should she get her kid a Gardasil shot. Gardasil (NYSE:MRK) is a vaccine that protects against infection with human papilloma virus (HPV). The virus causes genital warts and a number of cancers including cervical, penile, and oral cancers. The vaccine protects against these, but to be effective, it should be given before a child is sexually active (the usual advice is nine years old), an idea upsetting to some people.

The responses to her question ranged from "Do it!" to "Are you crazy? No way!" This gives us a great opportunity to examine her question and answer with facts that can help parents make decisions. There will be no "naming and shaming" here, just answers to the comments and questions culled from the discussion.

"Go read with Dr. Mercola has to say." If you're not familiar with the world of medical conspiracy theories, you might not be familiar with Joe Mercola, a family practice doc in Illinois. He is way out there. Those of us who monitor wacky and dangerous medical ideas think of his website as a "target-rich environment," a place to find the most misguided and false medical advice. This response is simply a call to recognize the authority of an internet doctor who has a terrible reputation among most other medical professionals. Needless to say, Mercola doesn't like Gardasil and publishes a ton of questionable pieces on the topic.

"The shots only prevent a few strands of the virus when there are so many more. My OBGYN also told me the other day that most young women will have HPV during their teen years but those cases should clear themselves up before they're 21." We'll ignore the incorrect biology here ("strands of the virus" probably means "strains," but the correct terminology is "types"). The truth is Gardasil only protects against four of the 120 types of HPV, but these are the types that matter. Types 16 and 18 cause about 70% of cervical cancers and nearly all of the other HPV-related cancers. Types 6 and 11 cause most genital warts, and while warts don't lead to cancer, they are certainly a public health problem. And while it's nice that "most cases should clear themselves up" this is not always the case. Pap smears are our current method of early detection for cervical cancer. The test is pretty good, but certainly not better than prevention. I would hate to deny someone the vaccine simply because the disease "should clear itself up," and then have to explain to them why they have cancer.

"Has your child tended to have bad reactions to other vaccinations? Does your child have food intolerances and allergies, or some other auto-immune problem? Then you might not want to give it ... But I guess if there is a chance that it saves some people from developing cervical cancer it is worth it if the child is otherwise healthy and robust." Allergies and "auto-immune" problems aren't relevant. In fact, people with immunodeficiencies such as HIV are much more susceptible to cervical cancer and other HPV-related cancers. A child does not have to be "otherwise healthy and robust" to benefit from the shot.

Other arguments against the HPV vaccine also fail to hold water. Despite sensational news reports, the shot has not caused an epidemic of fainting or led to deaths. The national Vaccine Adverse Event Reporting System (VAERS) is a clearinghouse for reports of vaccine side effects. It is simply a collection of people's stories and health officials try to follow up on them to see if they have any merit. If you wished, you could make a report to VAERS that Gardasil caused you to become a communist. It's a system designed to gather as much data as possible without regard to quality. The quality control comes on follow up, where most "reactions" have been found to be either minor ("irritation at injection site," "feeling faint") or unrelated to the vaccine.

Merck, the maker of Gardasil certainly hopes to profit from the drug (doctors usually make very little or even lose money on vaccines). The fact that there is a profit motive does not make the vaccine bad, it simply means that any data coming directly from Merck should be given a bit more scrutiny. The HPV vaccine is a good one, and protects against several important cancers. My kiddo is going to get it as soon as she next visits the doctor, and if I had a son, he'd get one too.

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog at Forbes. His blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.

Blog log

Members of the American College of
Physicians contribute posts from their own sites to
ACP Internistand ACP
Hospitalist. Contributors include:

Albert Fuchs,
MD
Albert Fuchs, MD, FACP, graduated from the
University of California, Los Angeles School of Medicine, where he
also did his internal medicine training. Certified by the American
Board of Internal Medicine, Dr. Fuchs spent three years as a
full-time faculty member at UCLA School of Medicine before opening
his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical
Student Member, is a first-year medical student at the OUWB School
of Medicine, charter class of 2015, in Rochester, Mich., from which
she which chronicles her journey through medical training from day
1 of medical school.

Auscultation Ira S. Nash,
MD, FACP, is the senior vice president and executive director of the North Shore-LIJ
Medical Group, and a professor of Cardiology and Population Health at Hofstra North
Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and
Cardiovascular Diseases and was in the private practice of cardiology before joining the
full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and
general internist in the Division of General Internal Medicine at
Johns Hopkins. His research interests include doctor-patient
communication, bioethics, and systematic reviews.

Controversies in Hospital
Infection Prevention
Run by three ACP
Fellows, this blog ponders vexing issues in infection prevention
and control, inside and outside the hospital. Daniel J Diekema, MD,
FACP, practices infectious diseases, clinical microbiology, and
hospital epidemiology in Iowa City, Iowa, splitting time between
seeing patients with infectious diseases, diagnosing infections in
the microbiology laboratory, and trying to prevent infections in
the hospital. Michael B. Edmond, MD, FACP, is a hospital
epidemiologist in Richmond, Va., with a focus on understanding why
infections occur in the hospital and ways to prevent these
infections, and sees patients in the inpatient and outpatient
settings. Eli N. Perencevich, MD, ACP Member, is an infectious
disease physician and epidemiologist in Iowa City, Iowa, who
studies methods to halt the spread of resistant bacteria in our
hospitals (including novel ways to get everyone to wash their
hands).

Suneel Dhand, MD, ACP Member Suneel Dhand, MD,
ACP Member, is a practicing physician in Massachusetts. He has published numerous
articles in clinical medicine, covering a wide range of specialty areas including;
pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also
authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His
other clinical interests include quality improvement, hospital safety, hospital
utilization, and the use of technology in health care.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more
than a decade and is an Associate Professor of Medicine at an
academic medical center on the East Coast. His time is split
between teaching medical students and residents, and caring for
patients.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the
Internal Medicine Residency and Assistant Dean of Scholarship &
Discovery at the Pritzker School of Medicine for the University of
Chicago. Her education and research focus is on resident duty
hours, patient handoffs, medical professionalism, and quality of
hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings
of medical practice and the complexities of hospital care,
illuminates the emotional and cognitive aspects of caregiving and
decision-making from the perspective of an active primary care
physician, and offers behind-the-scenes portraits of hospital
sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the
University of North Carolina School of Medicine, and the Program
Director for the GI & Hepatology Fellowship Program. He
specializes in diseases of the esophagus, with a strong interest in
the diagnosis and treatment of patients who have
difficult-to-manage esophageal problems such as refractory GERD,
heartburn, and chest pain.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned
authority on nutrition, weight management, and the prevention of
chronic disease, and an internationally recognized leader in
integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of
hematology and medical oncology. His blog is a joint publication
with Gregg Masters, MPH.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics
in medicine, health care news and culture. Her views on medicine
are informed by her past experiences in caring for patients, as a
researcher in cancer immunology, and as a patient who's had breast
cancer.

Mired in MedEd
Alexander M.
Djuricich, MD, FACP, is the Associate Dean for Continuing Medical
Education (CME), and a Program Director in Medicine-Pediatrics at
the Indiana University School of Medicine in Indianapolis, where he
blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice
internist, returns with "volume 2" of his personal musings about
medicine, life, armadillos and Sasquatch at More Musings (of a
Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a
small community hospital in Connecticut. His blog is a series of
musings on medicine, medical care, the health care system and
medical ethics, in no particular order.

The Blog of Paul Sufka
Paul Sufka,
MD, ACP Member, is a board certified rheumatologist in St. Paul,
Minn. He was a chief resident in internal medicine with the
University of Minnesota and then completed his fellowship training
in rheumatology in June 2011 at the University of Minnesota
Department of Rheumatology. His interests include the use of
technology in medicine.

Technology in (Medical)
Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in
education, social media and networking, practice management and
evidence-based medicine tools, personal information and knowledge
management.

Peter A. Lipson,
MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and
teaching physician in Southeast Michigan. The blog, which has been
around in various forms since 2007, offers musings on the
intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice
Boughton, MD, FACP, practiced internal medicine for 20 years before
adopting a career in hospital and primary care medicine as a locum
tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD,
FACP, is an internal medicine physician who has avidly applied
computers to medicine since 1986, when he first wrote medically
oriented computer programs. He is in practice in Tacoma,
Washington.

Other
blogs of note:

American Journal of
Medicine
Also known as the Green Journal, the American Journal of Medicine
publishes original clinical articles of interest to physicians in
internal medicine and its subspecialities, both in academia and
community-based practice.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so
he can create an independent, clinician-reviewed space on the
Internet for physicians to report and comment on the medical news
of the day.

PLoS Blog
The Public Library of Science's open access materials include a
blog.

White Coat
Rants
One of the most popular anonymous blogs written by an emergency
room physician.

ACP Internist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated